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Patient Registration Form.

Shore Dental

4901 White Ibis Drive,North Port, FL, 34287(941) 257-0826

Patient Details( * mandatory to fill )

First Name*

Last Name*

Middle Name

Date Of Birth*

Address*

City*

State*

Zip*

Gender*

Marital Status*

Social Security Number*

Driving License Number

Whom may we thank for referring you?

Spouse Name

Contact Information( * mandatory to fill )

Email*

Home Phone Number

Cell Phone Number*

Work Phone Number

Work Extension Number

I would like to receive correspondence via text

Employment Status

Full Time

Part Time

Retired

Profession

Do you have an out of town address?

Yes

No

if yes,please list months away

Out of town city state and zip

Phone Number

Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an interrelationship with the dentistry you will receive.Thank you for answering the following questions

Are you under a physician's care now?

yes

no

If Yes,

Have you ever had a serious head or neck injury?

yes

no

If Yes,

Are you taking any medications, pills or drugs?

yes

no

If Yes,

Do you take, or have you taken,phen-fen or Redux

yes

no

If Yes,

Have you ever taken Fosamax, Boniva,actonel or any other medications containing bisphosphonates?

yes

no

If Yes,

Have you ever been hospitalized or had a major operation?

Yes

No

If Yes ,Please Specify

Are you on a special diet?

yes

no

If yes, Please Specify

Do you use tobacco?

yes

no

Do you use controlled substances?

yes

no

If Yes,

Women, are you?

Pregnant/trying to get pregnant?

Nursing?

Taking oral contraceptives?

Are you allergic to any of the following?

Aspirin

Pencillin

Codeine

Acrylic

metal

Latex

sulfa drugs

Local anesthetics

Other

If Yes,

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes

No

Alzheimer's Disease

Yes

No

Anaphylaxis

Yes

No

Anemia

Yes

No

Angina

Yes

No

Arthritis/Gout

Yes

No

Artificial Heart Valves

Yes

No

Artificial Joints

Yes

No

Asthma

Yes

No

Blood Disease

Yes

No

Blood Transfusion

Yes

No

Breathing Problems

Yes

No

Bruise Easily

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Cold sores / Fever blisters

Yes

No

Congenital heart disorder

Yes

No

Convulsion

Yes

No

Cortisone medicine

Yes

No

Diabetes

Yes

No

Difficulty Breathing

Yes

No

Drug Addiction

Yes

No

Easily Winded

Yes

No

Emphysema

Yes

No

Epilepsy or Seizures

Yes

No

Excessive Bleeding

Yes

No

Excessive Thirst

Yes

No

Fainting spells / Dizziness

Yes

No

Frequent Cough

Yes

No

Frequent Diarrhea

Yes

No

Frequent Headaches

Yes

No

Genital Herpes

Yes

No

Glaucoma

Yes

No

Hay Fever

Yes

No

Heart Attack / Failure

Yes

No

Heart Murmer

Yes

No

Heart Pacemaker

Yes

No

Heart Trouble / Disease

Yes

No

Hemophilia

Yes

No

Hepatitis A

Yes

No

Hepatitis B or C

Yes

No

Herpes

Yes

No

High Blood Pressure

Yes

No

High Cholesterol

Yes

No

Hives or Rash

Yes

No

Hypoglycemia

Yes

No

Irregular Heartbeat

Yes

No

Kidney Problem

Yes

No

Leukemia

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Lung diseases

Yes

No

Mitral Value prolapse

Yes

No

Osteoporosis

Yes

No

Pain in Jaw Joints

Yes

No

Parathyroid Disease

Yes

No

Psychiatric Care

Yes

No

Radiation Treatments

Yes

No

Recent Weight Loss

Yes

No

Renal Dialysis

Yes

No

Rheumatic Fever

Yes

No

Rheumatism

Yes

No

Scarlet Fever

Yes

No

Shingles

Yes

No

Sickle Cell Disease

Yes

No

Sinus Trouble

Yes

No

Spina Bifida

Yes

No

Stomach/Intestinal Disease

Yes

No

Stroke

Yes

No

Swelling of Limbs

Yes

No

Yellow Jaundice

Yes

No

Thyroid Disease

Yes

No

Tonsillitis

Yes

No

Tuberculosis

Yes

No

Tumors or Growths

Yes

No

Ulcers

Yes

No

Venereal Disease

Yes

No

Have you ever had any serious illness not listed above?

Yes

No

if yes,please explain

Do you take Blood Thinners?

Yes

No

Do you take Bisphosphonate Drugs (le: Actonel and Fosamax)?

Yes

No

if yes,please explain

Preferred Pharmacy

Pharmacy Location & Phone

Current Medicines & Supplements

Please list name and phone numbers of all current Physicians

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status

( * mandatory to fill )

Reason for this visit

Date of last dental visit?

Have you had any difficulty with dental treatment in the past?

Yes

No

if yes,please explain

How often do you brush your teeth?

How often do you floss?

What other oral hygiene aids do you use?

Do your gums bleed while brushing or flossing?

Do you have tooth or gum pain with

Hot

Cold

Sweet

Biting

if yes,please explain

Do you have a history of bite problems?

Yes

No

If yes, please explain

Do you have a history of headaches?

Yes

No

if yes, please explain

Do you clench or grind your teeth?

Yes

No

if yes, please explain

Do you have a history of broken teeth or fillings?

Yes

No

If yes, please explain

Do you have a history of periodontal disease?

Yes

No

If yes, please explain

On a scale of 1 to 10, with 10 being the highest, what priority do you give your teeth and oral health?

1

2

3

4

5

6

7

8

9

10

What goals do you have with your teeth and oral health?

What current dental concerns do you have?

Are you happy with the appearance of your teeth and smile?

If you could change anything about your mouth or smile, what would it be?

What did you like most about your former dental office?

What did you like least about your former dental office?

Insurance Details( * mandatory to fill )

Relation To Patient

Subscriber Name

Insured SSN

EmployerName

Insured Person's Address

Subscriber's Birthdate

Subscriber ID

Insurance Company

Group Number

Insurance Company Address

Insurance Company City

Insurance Company State

Insurance Company ZipCode

It is important to understand that your actual insurance benefits may differ from the benefits estimated in your Treatment Plan Estimate. Your Treatment Plan Estimate is based on information provided by you and your insurance company. Please remember that it is only an estimate and your benefits may be higher or lower than what is estimated. In all cases, the cost of all dental care is ultimately the responsibility of the patient or their legal guardian, regardless of insurance coverage. Therefore, you are responsible for amounts not covered by your insurance, unless prohibited by law or contractual agreement. We encourage all patients to refer to their member handbooks or call their plan administrator with any questions or concerns relating to specific benefits.

I hereby authorize payment directly to Shore Dental all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

I authorize the above doctor and/or provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment.

I understand this information serves as:

A basis for planning my care and treatment,

A means of communication among health professionals who contribute to my care,

A source of information for applying my diagnosis and treatment information to my bill,

A means by which a third-party payer can verify that services billed were actually provided,

A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff.

I have been provided the opportunity to review the "Notice of Patient Privacy Information Practices" that provides a more complete description of information uses and disclosures. I understand that I have the following rights:

The right to review the "Notice" prior to acknowledging this consent, The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations.

I request the following restrictions on the use or disclosure of my health information

May discuss treatment, payment, or healthcare operation with the following persons

Please check all that apply

Spouse

Your Children

Relatives

Others

Parents

Please list the names and relationship, if you checked "Relatives" or "Others" above

Messages will be of a non-sensitive nature, suchas appointment reminders.

May we leave a message on your answering machine

At home

At work

Do not leave a message

May we leave a message with someone at your home using the doctor's name or the practice name

Yes

No

May we leave a message with someone at your work using the doctor's name or the practice name

Yes

No

I understand that as part of treatment, payment, or healthcare operations, it may become necessary to disclose health information to another entity, i.e. referrals to other healthcare providers, labs, and/or other individuals or agencies as permitted or required by state or federal law.

I fully understand and accept the information provided by this consent.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

Print name of person signing

If other than patient is signing, are you the parent, legal guardian, custodian, or have Power of Attorney for this patient, for treatment, payment or healthcare operations?*

Yes

No

Patient refused to sign the consent form

Restrictions were added by the patient (see restrictions listed above)

Consent form received and reviewed by

Consent form placed in the Patient's medical record on

Recieved & reviewed by

Date

FINANCIAL POLICY( * mandatory to fill )

Please read carefully and sign to acknowledge understanding and agreement

Thank you for choosing us as you dental care provider. We are committed to providing you with the best dental care available.

Available Payment Options.

You can choose from ~ Cash, Check, Visa, Mastercard, American Express

We offer a 5% courtesy adjustment to patients who pay for their treatment, at the time of Scheduling your next appointment.

CareCredit payment plan option, ask us for detailed information.

Regarding Insurance.

For covered services, we ask that all co-pays and deductibles be paid on the day of treatment. Since your insurance company may not cover all costs, we ask that you pay any percentage of your balance not paid by your insurance on the day of treatment.

For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment.

We will attempt to answer any questions we can about your insurance and, when possible We will assist in resolving complications with your insurance company. Please understand that We cannot Speak on their behalf. Your insurance contract is an agreement between you, your employer and your insurance carrier. In the event that your insurance company has not paid (on your behalf), you will be responsible to pay your account.

Patients Without Insurance.

For those patients without insurance coverage, you will be responsible for payment on the day of treatment. If you are not able to pay in full, or if your treatment requires several visits, you will be given an estimate and will be able to discuss payment arrangements with a member of our business office Staff.

Cancellation/No Show Policy.

Our office requires notice to cancel your appointment in the case of an emergency. We reserve the right to charge a fee, for those not giving notice.

Collections

A charge will be added to your account for any returned checks. You are responsible to pay all costs of collecting, or attempting to collect any debt owed on this account. This includes all attorneys fees, interest and late fees.

X-Rays.

You are responsible to pay a fee for duplicate copies of your X-rays.

I hereby authorize payment to

by the group insurance, otherwise payable to me.

SIGNATURE *

(Please click below to draw/upload sign)

(Your IP Address :
IP:34.236.153.51 )

HIPAA Information and Consent Form( * mandatory to fill )

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff . You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.

We agree to provide patients with access to their records in accordance with state and federal laws.

We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.

You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.